Download PDF

Document downloaded from http://www.elsevier.es, day 11/07/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Med Intensiva. 2014;38(6):391---401
www.elsevier.es/medintensiva
SCIENTIFIC LETTERS
Lesser accidental arterial catheter
removal with the femoral access than with
the cubital, dorsalis pedis and brachial
arterial accesses
Menor retirada accidental de catéter arterial
en el acceso femoral que en los accesos
cubital, dorsal del pie y braquial
Arterial catheterization is a frequent proceeding in critically ill to obtain repetitively blood sampling and continuous
monitoring of systemic arterial pressure arterial.1---3 The
incidence of accidental catheter removal (ACR) in arterial catheters has been scarcely studied,4---8 and we did not
find studies comparing the ACR incidence between femoral,
cubital, dorsalis pedis and brachial arterial sites. The importance of ACR lies in that could cause severe complications,
such as severe external haemorrhage and vascular damage,
and some could be potentially life-threatening. Thus, due
to the scarce published data and the possibility of severe
complications in relation to ARC of arterial catheters we
proposed this study. The objective of this study was to compare the incidence of ACR in femoral, cubital, dorsalis pedis
and brachial arterial sites.
We performed a retrospective study over seven years of
all patients who were undergoing to femoral, cubital, dorsalis pedis or brachial arterial catheterization during their
stay in the polyvalent Intensive Care Unit of the Hospital
Universitario de Canarias, Tenerife, Spain. The study was
approved by the institutional review board.
The following data were collected: age, sex, diabetes mellitus, APACHE-II, diagnosis group, catheter access,
catheter insertion and removal dates, and cause of catheter
removal (planned or accidental).
We considered accidental catheter removal as the presence of an unplanned removal produced by the patient or
the staff. The ACR can be performed by the patient, either
by taking hold of it with their hands or by making voluntary movements that led directly the removal. The ACR can
be performed by the staff as consequence of inadequate
handling. The catheters removed due to obstruction of the
catheter were not considered as ACR.
Statistical analyses were performed with SPSS 12.0.1
(SPSS Inc., Chicago, IL), LogXact 4.1 (Cytel Co., Cambridge,
MA) and StatXact 5.0.3 (Cytel Co., Cambridge, MA). Continuous variables are reported as medians and percentiles
25th---75th, and were compared using Mann---Whitney test.
Categorical variables are reported as frequencies and percentages, and were compared using Chi-square test. The
incidence of ACR between groups was compared using Cox
regression. The magnitude of the effects is expressed as Hazard Ratio (HR) and 95% confidence interval (CI). A p-value
less than 0.05 was considered statistically significant.
Were included a total of 2199 arterial catheters and
remain in situ during 13,237 days. We detected 116 ACR, thus
the 5.3% arterial catheters were accidentally removed and
we had 0.88 ACR per 100 days of arterial catheterization.
We found 49 events of ACR in 1250 (3.9%) arterial femoral
catheters during 7524 days of catheterization (0.65 events
of ACR per 100 days of catheterization), 39 events of ACR
in 583 (6.7%) arterial cubital catheters during 3513 days
of catheterization (1.11 events of ACR per 100 days of
catheterization), 15 events of ACR in 198 (7.6%) arterial
dorsalis pedis catheters during 1187 days of catheterization
(1.26 events of ACR per 100 days of catheterization) and
13 events of ACR in 168 (7.7%) arterial brachial catheters
during 1013 days of catheterization (1.28 events of ACR per
100 days of catheterization), As shown in Table 1, there
were no significant differences between femoral, cubital,
dorsalis pedis and brachial arterial catheters in age, sex,
diabetes mellitus, APACHE-II, diagnosis group and duration
of the catheter. However, there were found statistically significant differences in the percentage of catheters with ACR
(p = 0.01) and in the ACR incidence per 100 days of catheterization (p = 0.02) between the different arterial sites.
Cox regression analysis showed a lower ACR incidence in femoral than in cubital (Hazard Ratio = 0.608;
95% CI = 0.399---0.926; p = 0.02), dorsalis pedis (Hazard
Ratio = 0.534; 95% CI = 0.299---0.952; p = 0.03) and brachial
(Hazard Ratio = 0.500; 95% CI = 0.271---0.922; p = 0.03) arterial catheters (Table 2).
To our knowledge, this is the first study comparing ACR
incidence between femoral, cubital, dorsalis pedis and
brachial arterial sites. The most relevant finding of our
study is that femoral arterial catheter showed a lower ACR
incidence that cubital, dorsalis pedis and brachial arterial
catheters.
In our study, we found that the 5.3% of arterial catheters
were accidentally removed and an ACR rate of 0.88 events
per 100 days of arterial catheterization. Our ACR rate is
0210-5691/$ – see front matter © 2013 Elsevier España, S.L. and SEMICYUC. All rights reserved.
Document downloaded from http://www.elsevier.es, day 11/07/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
392
Table 1
SCIENTIFIC LETTERS
Characteristics of different arterial catheters.
Arterial catheter site
Femoral
(n = 1250)
Cubital
(n = 583)
Age-years median (25th---75th p)
Sex, female --- number (%)
Diabetes mellitus --- number (%)
APACHE-II --- score median (25th---75th p)
Diagnosis group --- number (%)
Cardiologic
Respiratory
Digestive
Neurological
Traumatology
Intoxication
60
524
404
13
(46---70)
(41.9)
(32.3)
(10---17)
62
241
190
13
(48---68)
(41.3)
(32.6)
(10---17)
60
84
68
13
(50---68)
(42.4)
(34.3)
(9---17)
62
77
57
12
(52---69)
(45.8)
(33.9)
(9---17)
288
203
86
292
322
59
(23.0)
(16.2)
(6.9)
(23.4)
(25.8)
(4.7)
123
100
45
136
151
28
(21.1)
(17.2)
(7.7)
(23.3)
(25.9)
(4.8)
45
34
10
52
50
7
(22.7)
(17.2)
(5.1)
(26.3)
(25.3)
(3.5)
40
30
8
39
42
9
(23.8)
(17.9)
(4.8)
(23.2)
(25.0)
(5.4)
6 (5---7)
49 (3.9%)
0.65
Catheter duration --- days median (25th---75th p)
ACR --- number (%)
ACR per 100 days of catheterization
Dorsalis
pedis
(n = 198)
6 (4---8)
39 (6.7%)
1.11
6 (4---8)
15 (7.6%)
1.26
Brachial
(n = 168)
6 (5---7)
13 (7.7%)
1.28
p
0.92
0.77
0.93
0.58
0.99
0.99
0.01
0.02
ACR: accidental catheter removal; p: percentile.
Table 2
Comparisons of ACR incidence between different arterial sites.
ID
Femoral vs cubital
Femoral vs dorsalis pedis
Femoral vs brachial
Cubital vs dorsalis pedis
Cubital vs brachial
Dorsalis pedis vs brachial
0.65
0.65
0.65
1.11
1.11
1.26
vs
vs
vs
vs
vs
vs
1.11
1.26
1.28
1.26
1.28
1.28
HR --- 95% CI
p-Value
0.608
0.534
0.500
0.873
0.823
0.943
0.02
0.03
0.03
0.65
0.54
0.88
(0.399---0.926)
(0.299---0.952)
(0.271---0.922)
(0.481---1.583)
(0.439---1.542)
(0.448---1.985)
ACR: accidental catheter removal; ID: incidence density (defined as number of ACR per 100 catheter-days); HR: hazard ratio; CI:
confidence interval.
in the limit low according the previously reported rates,
which is range between 3.8 and 18.4% catheters and of 1.17--1.8 events of ACR per 100 days of catheterization.4---8
In addition, we found for the first time that femoral arterial catheter showed a lower ACR incidence that cubital,
dorsalis pedis and brachial arterial catheters. This is a novel
aspect in relation to ACR of arterial catheters due to that
previously was not reported a comparison of ACR between
these arterial sites.
In a previous study of our team,9 we did not find significant differences in the ACR rate between 1057 radial,
125 femoral, 30 dorsalis pedis and 19 brachial arterial sites.
Afterwards, increasing the sample size to 2419 radial and
1085 femoral arterial catheters was found a lower ACR in
femoral than in radial arterial catheter.10 In the same way,
the increase of sample size to 1250 femoral, 583 cubital,
198 dorsalis pedis and 168 brachial arterial sites could contributed in the appearance of significant differences in our
current study.
Whereas the strength of our study was the relatively
large sample size compared with previous studies,4---8 some
limitations should be recognized. First, there was not a randomization in the different arterial catheter site and the
site was chose by criteria physician. Second, cubital, dorsalis pedis and brachial arterial catheters were fixed by
steri-strip, and femoral arterial catheters were fixed by silk
suture. Despite these limitations, we think that the results
of our study could contribute to know more about ACR in
critically ill patient.
In conclusion, ACR is a frequent complication between
the critically ill patients and is another important aspect of
patient safety. In our study, the arterial femoral site showed
a lower risk of ACR than cubital, dorsalis pedis and brachial
arterial sites.
Fundings
This study was supported, in part, by a grant from Instituto
de Salud Carlos III (I3SNS-INT-11-063 and I3SNS-INT-12-087)
(Madrid, Spain).
References
1. Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas
MH, EPIC International Advisory Committee. The prevalence of
nosocomial infection in intensive care units in Europe. J Am Med
Assoc. 1995;274:639---44.
2. Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A.
Prospective study of peripheral arterial catheter infection and
Document downloaded from http://www.elsevier.es, day 11/07/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
SCIENTIFIC LETTERS
3.
4.
5.
6.
7.
8.
comparison with concurrently sited central venous catheters.
Crit Care Med. 2008;36:397---402.
Lucet JC, Bouadma L, Zahar JR, Schwebel C, Geffroy A, Pease
S, et al. Infectious risk associated with arterial catheters
compared with central venous catheters. Crit Care Med.
2010;38:1030---5.
Amo Priego MD, Carmona Monge FJ, Gómez Nieves I, Bonilla
Zafra G, Gordo Vidal F. Assessment of the efficacy of the
implementation of an arterial cannulation protocol as quality
assurance method. Enferm Intensiva. 2004;15:159---64.
Carrión M, Ayuso D, Marcos M, Robles P, de la Cal MA, Alía I, et al.
Accidental removal of endotracheal and nasogastric tubes and
intravascular catheters. Crit Care Med. 2000;28:63---6.
Marcos M, Ayuso D, González B, Carrión M, Robles P, Muñoz
M. Analysis of the accidental withdrawal of tubes, probes and
catheters as a part of the program of quality control. Enferm
Intensiva. 1994;5:115---20.
García MP, López P, Eseverri C, Zazpe C, Asiain MC. Quality of
care in intensive care units. Retrospective study on long-term
patients. Enferm Intensiva. 1998;9:102---8.
Goñi Viguria R, García Santolaya MP, Vázquez Calatayud M, Margall Coscojuela MA, Asiaín Erro MC. Evaluation of care quality
Evaluación diaria del protocolo
FASTHUG y resultados a corto
plazo
Daily evaluation of the FASTHUG protocol and
short-term outcomes
El uso de protocolos y guías de actuación clínica en el ámbito
de cuidados intensivos ha demostrado mejorar la seguridad
y la eficacia de los cuidados médicos1 , especialmente en
situaciones puntuales, como el «weaning» de la ventilación
mecánica2 , la prevención de la sepsis por catéter3 o el control de la glucosa4 , aunque este último haya sido algo más
controvertido en los últimos años.
Para situaciones más complejas, como pueda ser el
manejo de un paciente séptico, del soporte nutricional o del
SDRA, los protocolos o guías clínicas tienen tantos «flecos»
que se hacen excesivamente complicados5,6 . Es en estos
casos donde como alternativa, surgen los «checklist», que
tienen como objetivo mejorar la seguridad y la calidad de
los cuidados a nuestros pacientes.
Hemos analizado prospectivamente a todos los pacientes
que han ingresado durante el mes de marzo de 2013
en UCI y han permanecido más de 48 h, recogiendo un
«checklist» propuesto por Vincent et al.7 , conocido por la
regla mnemotécnica FASTHUG (Feeding, Analgesia, Sedation, Thromboembolic prevention, Head elevation, Ulcer
profilaxis y Glucose control), durante todos los días de
ingreso, sin que los médicos y enfermeros encargados
de los pacientes fueran conscientes de ello para así evitar
que modificaran su práctica habitual.
Se incluyó a 95 pacientes (28 hombres), con un APACHE
II al ingreso de 17,68 ± 9,1 puntos y una estancia media de
4 ± 2 días. La mortalidad bruta fue del 14,5%. El porcentaje
de cumplimiento de los diferentes ítems fue elevado,
oscilando desde el 73,6 hasta casi el 100%. En un 27,3% de
393
in the ICU through a computerized nursing care plan. Enferm
Intensiva. 2004;15:76---85.
9. Lorente L, Huidobro MS, Martín MM, Jiménez A, Mora ML. Accidental catheter removal in critically ill patients: a prospective
and observational study. Crit Care. 2004;8:229---33.
10. Lorente L, Brouard MT, Roca I, Jiménez A, Pastor E, Lafuente
N, et al. Lesser incidence of accidental catheter removal
with femoral versus radial arterial access. Med Intensiva.
2013;37:316---9.
L. Lorente a,∗ , L. Lorenzo a , R. Santacreu a , A. Jiménez b ,
J. Cabrera a , C. Llanos a , M.L. Mora a
a
Department of Intensive Care, Hospital Universitario
de Canarias, La Laguna, Santa Cruz
de Tenerife, Spain
b
Research Unit, Hospital Universitario de Canarias,
La Laguna, Santa Cruz de Tenerife, Spain
∗
Corresponding author.
E-mail address: [email protected] (L. Lorente).
http://dx.doi.org/10.1016/j.medin.2013.07.009
pacientes se realizó al 100% el cumplimiento en todos los
ítems y en todos los días de ingreso. Fueron estos pacientes
con cumplimiento del 100% los que tuvieron menor estancia
media (p = 0,014).
El ítem menos cumplimentado fue el control glucémico
(73,6%), siendo menos cumplimentado en los pacientes no
diabéticos (61,9%) que en los diabéticos (92,6%) (p = 0,0001).
En la tabla 1 se muestran las definiciones utilizadas y el porcentaje de cumplimiento de cada ítem. La mortalidad se
relacionó con la gravedad al ingreso ya fuera por APACHE
II (p = 0,002) o SAPS III (p = 0,0001). El cumplimiento de
cualquier ítem por separado o en su conjunto no se relacionó
con mejor pronóstico.
La comunicación del equipo multidisciplinar encargado
del cuidado del paciente a la cabecera del paciente es una
práctica que ha demostrado mejores resultados. Es en este
entorno donde los «checklist» como este tienen utilidad, ya
que permiten dar respuesta a estas preguntas por parte de
todo el equipo8 .
La SEMICYUC estableció en 2008 los indicadores de calidad en cuidados intensivos9 , donde
se encuentran todos los procesos incluidos en el
FASTHUG. De hecho, se establecieron los 20 indicadores principales, entre los que podemos encontrar
los componentes de dicho «checklist» salvo el
control de glucemia, probablemente influido por los
resultados contradictorios en trabajos posteriores a los
publicados por van den Berge et al.4
A pesar de que no están todos los indicadores, los
que están sí son importantes, y aunque algunos autores
proponen variaciones o adaptaciones para completar esta
regla mnemotécnica (FASTHUG-BID)10 , otros sostienen que
debería ser lo más simple posible para tenerla siempre en
mente y que de ese modo sea aplicable7 .
Con los métodos informáticos de hoy en día, parece
más sencilla la aplicabilidad de este sistema, ya que los
tratamientos arrastran de un día para otro las medidas